Effects of Different SARS-CoV-2 Testing Strategies in the Emergency Department on Length of Stay and Clinical Outcomes: A Randomised Controlled Trial.

The turn-around-time (TAT) of diagnostic and screening measures such as testing for SARS-CoV-2 can affect a patient's length of stay (LOS) in the hospital as well as the emergency department (ED). This, in turn, can affect clinical outcomes. Therefore, a reliable and time-efficient SARS-CoV-2 testing strategy is necessary, especially in the ED. In this randomised controlled trial, n = 598 ED patients presenting to one of three university hospital EDs in Berlin, Germany, and needing hospitalisation were randomly assigned to two intervention groups and one control group. Accordingly, different SARS-CoV-2 testing strategies were implemented: rapid antigen and point-of-care (POC) reverse transcription polymerase chain reaction (rtPCR) testing with the Roche cobas® Liat® (LIAT) (group one n = 198), POC rtPCR testing with the LIAT (group two n = 197), and central laboratory rtPCR testing (group three, control group n = 203). The median LOS in the hospital as an inpatient across the groups was 7 days. Patients' LOS in the ED of more than seven hours did not differ significantly, and furthermore, no significant differences were observed regarding clinical outcomes such as intensive care unit stay or death. The rapid and POC test strategies had a significantly (p < 0.01) shorter median TAT (group one 00:48 h, group two 00:21 h) than the regular central laboratory rtPCR test (group three 06:26 h). However, fast SARS-CoV-2 testing strategies did not reduce ED or inpatient LOS significantly in less urgent ED admissions. Testing strategies should be adjusted to the current circumstances including crowding, SARS-CoV-2 incidences, and patient cohort. This trial is registered with DRKS00023117.

High-sensitivity cardiac troponin T for diagnosis of NSTEMI in the elderly emergency department patient: a clinical cohort study.

PURPOSE: The aim of this study is to evaluate the impact of age on the diagnostic performance of high-sensitivity troponin T (hsTnT) under routine conditions. MATERIALS AND METHODS: Data of 4118 consecutive emergency department (ED) patients who underwent a routine TnT measurement between 11 October 2012 and 30 November 2013 were analysed. Diagnostic accuracy of hsTnT was compared in four age categories (<50, 50-64, 65-74, ≥75 years of age) for different cut-off values. Primary endpoint was a main hospital diagnosis of NSTEMI. RESULTS: The median age of the study population (n = 4118) was 61 years (IQR: 45-75 years). NSTEMI was diagnosed in 3.3% (n = 136) of all patients. There were significant differences in hsTnT concentrations between age-groups (p < 0.001) in all patients, but not in NSTEMI patients (p = 0.297). 72.2% of all patients ≥75 years of age (583/808) without NSTEMI had hsTnT concentrations above the 99th percentile of a healthy reference population. Specificity at 14 ng/L was 93.6% (95% CI: 92.12-94.87) in patients below 50 years of age and 27.9% (95% CI: 24.78-31.08) in patients 75 years of age and older. CONCLUSIONS: Patients' age needs to be considered at least one influencing factor on hsTnT concentrations at admission and should be included in the clinical interpretation of hsTnT concentrations for further clinical workup beneath other influencing factors like comorbidities and symptom onset time. The implementation of age-specific cut-off values could be considered for single troponin testing at admission but is associated with an increased risk of underdiagnosis of NSTEMI.

Heparin strongly induces soluble fms-like tyrosine kinase 1 release in vivo and in vitro--brief report.

OBJECTIVE: Soluble fms-like tyrosine kinase 1 (sFlt1) is involved in the pathophysiology of preeclampsia and coronary artery disease. Because sFlt1 has a heparin-binding site, we investigated whether or not heparin releases sFlt1 from the extracellular matrix. METHODS AND RESULTS: We measured sFlt1 before and after heparin administration in 135 patients undergoing coronary angiography, percutanous coronary intervention, or both. sFlt1 was increased directly after heparin administration (from 254 to 13,440 pg/mL) and returned to baseline within 10 hours. Umbilical veins and endothelial cells treated with heparin released sFlt1. Heparinase I and III also increased sFlt1. Mice treated with heparin had elevated sFlt1 serum levels. Their serum inhibited endothelial tube formation. CONCLUSIONS: Heparin releases sFlt1 by displacing the sFlt1 heparin-binding site from heparan sulfate proteoglycans. Heparin could induce an antiangiogenic state.

Soluble fms-like tyrosine kinase-1 (sFLT-1) predicts post-percutaneous coronary intervention (PCI) myocardial infarction (MI type 4a).

CONTEXT: Acute myocardial infarction (AMI) related to percutaneous coronary intervention (PCI) (MI type 4a) occurs in up to 26% of elective patients. OBJECTIVE: To evaluate if sFLT-1 helps to predict MI type 4a in troponin negative patients with elective PCI. MATERIALS AND METHODS: We enrolled 135 patients, 106 had a PCI. sFLT-1 levels were assessed at five time points before and after PCI. RESULTS: MI type 4a occurred in 22.1% of patients. sFLT-1 levels at admission above 251 pg/mL indicated a significant relative risk for MI type 4a of 2.83. CONCLUSION AND DISCUSSION: Increased sFLT-1 levels at baseline might indicate unstable atherosclerosis and risk for microembolization and thus be predictive of MI type 4a.

SARS-CoV-2 screening in patients in need of urgent inpatient treatment in the Emergency Department (ED) by digitally integrated point-of-care PCR: a clinical cohort study.

Patients in need of urgent inpatient treatment were recruited prospectively. A rapid point of care polymerase chain reaction test (POC-PCR; Liat®) for SARS-CoV2 was conducted in the Emergency Department (ED) and a second PCR-test from the same swab was ordered in the central laboratory (PCR). POC-PCR analyzers were digitally integrated in the laboratory information system. Overall, 160 ED patients were included. A valid POC-PCR-test result was available in 96.3% (n = 154) of patients. N = 16 patients tested positive for Severe Acute Respiratory Syndrome-Corona Virus 2 (10.0%). The POC PCR test results were available within 102 minutes (median, interquartile range: 56-211), which was significantly earlier compared to the central laboratory PCR (811 minutes; interquartile range: 533-1289, P < 0.001). The diagnostic accuracy of the POC-PCR test was 100%. The implementation and digital laboratory information system integration was successfully done. Staff satisfaction with the POC process was high. The POC-PCR testing in the ED is feasible and shows a very high diagnostic performance. Trial registration: DRKS00019207.

Diagnostic performance of a high-sensitive troponin T assay and a troponin T point of care assay in the clinical routine of an Emergency Department: A clinical cohort study.

BACKGROUND: A point of care test (POCT) for troponin T (TnT) in the Emergency Department (ED) was compared to a high-sensitivity TnT (hsTnT) central laboratory test (CLT) to determine the influence of test system and different cut-off values on the diagnostic performance in patients with suspected acute coronary syndrome (ACS) under routine conditions. METHODS: All patients with routine TnT testing in the ED were enrolled. Only internal medicine patients without STEMI and with both troponin values were analyzed. TnT was measured with a contemporary sensitive POCT assay in the ED and with a hs-assay in the central laboratory. The diagnostic performance was analyzed at two different cut-off points (99th percentile and conventional rule-in cut-offs). Primary endpoint was the diagnosis of NSTEMI. RESULTS: Of all patients (n=3423), 3.6% had a diagnosis of NSTEMI (n=124). For the hsTnT assay, 28.4% of all values were at or below the lower limit of detection (LOD) as compared to 75.7% of the POC-TnT-values. The area under the receiver operating curves did not differ significantly between the assays (hsTnT: 0.912(95%-CI: 0.884-0.940); POC-TnT: 0.896(95%-CI: 0.859-0.933)). The diagnostic performance was very similar for both assays: the positive predictive value was below 50% for troponin values below 100ng/L and hardly increased for values between 100 and 600ng/L for hs and conventional assays. CONCLUSIONS: In our cohort of emergency patients, the diagnostic performance of conventional POC-testing was comparable to hsTnT. A 99th percentile cut-off may be useful for rule-out of NSTEMI, but seems limited for routine rule-in strategies.

Usefulness of Beta2-Microglobulin as a Predictor of All-Cause and Nonculprit Lesion-Related Cardiovascular Events in Acute Coronary Syndromes (from the PROSPECT Study).

In the Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT) study, plaque burden, plaque composition, and minimal luminal area were associated with an increased risk of adverse cardiovascular events arising from untreated atherosclerotic lesions (vulnerable plaques) in patients with acute coronary syndromes (ACS). We sought to evaluate the utility of biomarker profiling and clinical risk factors to predict 3-year all-cause and nonculprit lesion-related major adverse cardiac events (MACEs). Of 697 patients who underwent successful percutaneous coronary intervention (PCI) for ACS, an array of 28 baseline biomarkers was analyzed. Median follow-up was 3.4 years. Beta2-microglobulin displayed the strongest predictive power of all variables assessed for all-cause and nonculprit lesion-related MACE. In a classification and regression tree analysis, patients with beta2-microglobulin >1.92 mg/L had an estimated 28.7% 3-year incidence of all-cause MACE; C-peptide <1.32 ng/ml was associated with a further increase in MACE to 51.2%. In a classification and regression tree analysis for untreated nonculprit lesion-related MACE, beta2-microglobulin >1.92 mg/L identified a cohort with a 3-year rate of 18.5%, and C-peptide <2.22 ng/ml was associated with a further increase to 25.5%. By multivariable analysis, beta2-microglobulin was the strongest predictor of all-cause and nonculprit MACE during follow-up. High-density lipoprotein (HDL), transferrin, and history of angina pectoris were also independent predictors of all-cause MACE, and HDL was an independent predictor of nonculprit MACE. In conclusion, in the PROSPECT study, beta2-microglobulin strongly predicted all-cause and nonculprit lesion-related MACE within 3 years after PCI in ACS. C-peptide and HDL provided further risk stratification to identify angiographically mild nonculprit lesions prone to future MACE.